11.1 Prescribing and administering
A prescription for eye preparations should specify if a separate bottle is
needed for each eye and if preservative free drops or single dose
units are required. It should be
specified whether the right, left or both eyes are to be treated. The
abbreviations RE, LE and R+L may be used but not BE because of potential confusion. For
outpatient prescriptions a stop date is needed if treatment is to finish before
the next visit.
For all eye drops the recommended dose is one drop because of the limited size
of the conjunctival sac. If different drops are to be
given at the same time of day there should be an interval of about 3 mins between treatments. Preparations that sting should be
given last. Systemic absorption via the nasal mucosa may be a problem with some
drugs, eg beta blockers or adrenaline, and this can
be minimised by compressing the lacrimal sac at the
medial canthus for 1min during and after
administration.
Preservative-free eye drops should be considered: (i)
when a patient becomes ‘sensitive’ to preservatives, (ii) in order to lessen
the preservative load when a patient is using a considerable number of eye drops
(ie more than three), (iii) in the short term where
inflammation (eg allergic conjunctivitis) makes it
difficult to detect an adverse effect of the preservative in the additional eye
drops.
Various aids can help the elderly or handicapped to give their own eye drops
and details are available at the Pharmacy.
Eye ointments are used for local treatment of lids, for prolonged treatment at
night and to reduce the number of drops given. If drops and ointment are used
at the same time, drops should be given first.
11.2 Control of microbial
contamination
All eye preparations are sterile when issued. They should be used with care
to prevent contamination of contents and to avoid the spread of infection from
one eye to the other.
For outpatients using multidose eye drops without
preservative, 1 bottle is issued per week to treat one or both eyes. The bottle
should be refrigerated and then discarded 7 days after opening. For multidose eye drops with preservative, 1 bottle per month
is supplied to treat one or both eyes and this should be discarded 1 month
after opening.
For inpatients fresh eye drops should be used on admission and after ophthalmic
surgery. Each bottle should be labelled with the patient's forename and
surname, the date opened and the eye(s) to be treated. One bottle should be
used to treat both eyes except for antibiotic drops or when a separate bottle
is specifically requested for each eye.
Preserved eye drops should be discarded after 14 days. Unpreserved drops should
be stored in a refrigerator and discarded after 7 days.
All drops used in the operating theatres should be single use and if taken from
a multidose container it should be discarded after
single use. In the A&E department and outpatient clinics single use drops
should be used whenever possible. Preserved drops in multidose
containers may be reused but must be discarded after 12hrs in the A&E Dept
and after each half day session in Outpatients. Drops should always be
discarded after use in cases of suspected infection or if there is doubt about
their quality.
11.3.1 Antibacterials
Ocular infections including conjunctivitis and blepharitis
are best treated with chloramphenicol. If they
fail to resolve quickly they should be referred to the Ophthalmology Dept.
Combined antibiotic and steroid preparations are not recommended for
non-specialist use.
First choices: Chloramphenicol eye
drops: 0.5% [10ml £2.05].
Chloramphenicol eye ointment: 1.0% [4g
£2.08].
Dose: For conjuctivitis the dose should vary
according to severity. For severe infections 1 drop should be given every hour,
reducing to 1 drop 4 times daily. Ointment should be considered for use at
night. Treatment should be given until 48hrs after symptoms have resolved. For blepharitis the lid margins should be cleaned with cotton
wool soaked in water and the ointment then massaged into the area 2-4 times
daily.
Caution: Sensitivity to chloramphenicol,
transient stinging with drops; aplastic anaemia
occurs rarely.
For expert use:
Cefuroxime preservative-free eye drops: 5% [5ml £16.80].
Chloramphenicol single use eye drops: 0.5%
[20 x 0.5ml £9.55].
Fusidic acid eye drops: 1% [5g £1.96].
Gentamicin eye drops: 0.3% (for
Pseudomonas) [10ml £2.13].
Gentamicin Forte eye drops: 1.5% (Moorfields) [5ml £17.92].
Gentamicin Forte preservative-free eye
drops: 1.5% (Moorfields) [5ml £18.73].
Ofloxacin eye drops: 0.3% [5ml, £2.17].
Penicillin preservative-free eye drops: 5,000 units/ml
(for Strep, ophthalmia neonatorum).
Prepared by NDDH pharmacy - unlicensed.
Propamidine eye drops: 0.1% (for acanthamoeba) [10ml £2.80]
11.3.2 Antifungals
Ocular mycosis requires expert treatment. Specialist eye drops from Moorfields are available at the Pharmacy.
11.3.3 Antivirals
First choice: Aciclovir eye ointment: 3% [4.5g £9.34]. Dose: for herpes simplex keratitis apply 5 times daily (every 4hrs) and continue for at least 3 days after healing is complete. Caution: Hypersensitivity to aciclovir; mild stinging after application; local irritation and inflammation. Steroid preparations should not be used in combination with antivirals.
Steroid eye drops are used for noninfected
inflammatory conditions of the eye. They should usually be prescribed only
after consultation with an ophthalmologist to minimise risk of masking an
underlying condition, exacerbating an infection or causing steroid glaucoma.
Dose frequency should vary according to the severity of inflammation, being
tailed off gradually to avoid rebound inflammation.
Prednisolone 1% and dexamethasone
0.1% are about equivalent in potency.
Prednisolone, betamethasone
and dexamethasone are readily absorbed and
effective in treating internal inflammation; fluorometholone
is absorbed to a lesser degree and has a mainly surface action.
First choice: Prednisolone eye drops: 0.5%
[10ml £2.00]. Dose: 1 drop every 1-2hrs until control is achieved, then
reduced gradually.
Caution: Systemic side effects may occur after prolonged use.
Other strengths of prednisolone:
Prednisolone eye drops: 1% (Pred-Forte®) [10ml £3.05].
Prednisolone eye drops: 0.1% (Moorfields) [10ml £10.84].
Prednisolone preservative free eye drops: 0.5%
(
Prednisolone preservative free eye drops: 1%
(
Prednisolone single use eye drops: 0.5%
[20 x 0.5ml £10.08].
Other steroid preparations:
Betamethasone eye drops: 0.1% [10ml
£2.23]. Dose and caution as for prednisolone.
Betamethasone eye ointment: 0.1% [3g
£1.41].
For expert use:
Dexamethasone eye drops: 0.1% (Maxidex®) [5ml £1.42].
Dexamethasone preservative free eye drops: 0.1%
(Moorfields) [8ml £7.90].
Dexamethasone single use eye drops: 0.1%
[20 x 0.5ml £9.38].
Fluorometholone eye drops: 0.1% [5ml
£1.71].
Corticosteroid eye preparations combined with antibiotics should be used only
for post-operative inflammation when bacterial infection is likely.
For expert use:
Betamethasone 0.1% with neomycin 0.5% eye drops:
[10ml £2.32].
Maxitrol® eye drops: (dexamethasone + neomycin + polymyxin)
[5ml £1.68].
Maxitrol® eye ointment: (dexamethasone + neomycin + polymyxin)
[3.5g £1.44].
Prednisolone 0.5% with neomycin 0.5% eye
drops: [10ml £2.00].
Caution: risk of neomycin toxicity at high doses.
Intravitreal corticosteroids
|
Link to NICE guidance |
For expert use only:
Dexamethasone 700 microgram intravitreal
implant: Ozurdex [£870.00].
11.4.2 Other anti-inflammatory preparations
First choice: Sodium cromoglicate eye drops:
2% [13.5ml £1.86].
Dose: for vernal catarrh and allergic conjuctivitis,
1 drop 4 times daily, or the ointment applied 2-3 times daily or at night. The
full effect may develop over several days and treatment may be needed for the
period of exposure to allergen. Caution: Allergy to preservative;
transient nasal stinging.
Also:
Otrivine-Antistin® eye drops: [10ml £2.35].1
drop 2 or 3 times daily
For expert inpatient use:
11.5 Mydriatics and cycloplegics
First choice (for ocular examination): Tropicamide
single use eye drops: 1% w/v [20 x 0.5ml £9.01]. Dose: 2 drops at
5min intervals with a further 1-2 drops after 30mins if needed (onset of action
20mins, duration 6-8hrs).
Caution: Photophobia may occur if the filtration angle is narrow;
driving should be avoided until vision has returned to pre-treatment level.
For expert use:
Atropine sulphate eye drops: 1% [10ml £1.11].
Atropine sulphate single use eye drops: 1% [20 x 0.5ml £12.71].
Cyclopentolate eye drops: 0.5% [5ml
£6.73] 1% [5ml £6.73].
Cyclopentolate single use eye drops: 0.5%
& 1% [20 x 0.5ml £9.64].
Homatropine eye drops: 1% [10ml £2.57];
2% [10ml £2.71].
Phenylephrine single use eye drops:
2.5% [20 x 0.5ml £9.53].
Phenylephrine eye drops: 10% [10ml £4.65].
Phenylephrine single use eye drops: 10%
[20 x 0.5ml £9.53].
Tropicamide eye drops: 0.5% [5ml
£1.29]; 1% [5ml £1.60].
Tropicamide single use eye drops: 0.5%
& 1% [20 x 0.5ml £9.01].
|
Link to NICE guidance |
Diagnosis and management of glaucoma. Clinical Guideline No.85 |
Treatment for glaucoma should be started and changed by an ophthalmologist.
Beta blockers
First choice: Timolol eye drops: 0.25% [5ml
£1.53], 0.5%, [5ml £1.54].
Dose: initially 1 drop of 0.25% solution, increased to 0.5% if response
is inadequate.
Also:
Timolol single use eye drops: 0.25% [30 x 0.2ml
£8.45], 0.5% [30 x 0.2ml £9.65]
Betaxolol eye drops: 0.5% [5ml £1.90].
Caution: Ocular irritation, burning, itching and pain, decreased corneal
sensitivity, diplopia and ptosis.
Systemic absorption occurs and therefore beta-blocker eye drops are
contra-indicated in patients with bradycardia, heart block
or uncontrolled heart failure.
CSM Warning: The CSM has advised that beta-blockers, even those with apparent
cardioselectivity, should not be used in patients
with asthma or a history of obstructive airways disease, unless no alternative
treatment is available. In such cases the risk of increasing bronchospasm should be appreciated and appropriate
precautions taken.
For drug interactions see BNF Appendix 1.
Carbonic anhydrase inhibitors
Dorzolamide eye drops are used together
with a topical beta-blocker, or alone if this is contra-indicated. Side effects
are similar to those of systemic sulphonamides.
For expert use:
Dorzolamide 2%
eye drops: [5ml £5.88]. Dose:
apply three times daily if used alone, twice daily if used with a topical
beta-blocker.
Dorzolamide 2% single use eye drops: [60 x 0.2ml £24.18]. Dose: apply
three times daily if used alone, twice daily if used with a topical beta-blocker.
Dorzolamide 2% + timolol
0.5% eye drops: (Cosopt®) [5ml £9.06].
Dose: apply twice daily.
Dorzolamide 2% + timolol
0.5% eye drops single use eye drops: (Cosopt®)
[60 x 0.2ml £28.59]. Dose: apply twice daily.
Also:
Brinzolamide eye drops: 1% (Azopt®)
[5ml £6.56]. Dose: Apply twice a day, increasing to three times a day if
necessary.
Also:
Acetazolamide tabs: 250mg [14 tabs £1.81]. Dose:
1-2 tabs initially then 1-4 tabs 4 times daily in divided doses.
Caution: Sensitivity to sulphonamides; renal failure and renal tubular
acidosis; adrenal insufficiency; conditions with sodium or potassium depletion.
Adverse effects include polydipsia, polyuria, potassium depletion, metabolic acidosis, crystalluria and renal calculi, paraesthesiae
of extremities, anorexia and weight loss, rashes and rarely blood disorders.
Acetazolamide sustained release caps: 250mg
[14 caps £7.77].
Acetazolamide injection: 500mg
[£14.76].
Alpha2 adrenoreceptor agonists
Brimonidine, a selective alpha2-adrenoreceptor
stimulant, is used for open-angle glaucoma and ocular hypertension when other
drugs, particularly beta-blockers, are inappropriate.
For expert use:
Brimonidine eye drops: 0.2% [5ml £3.78]. Dose:
one drop twice daily.
Prostaglandin analogues
Latanoprost are prostaglandin analogues which
increase uveoscleral outflow. They are used to reduce
intra-ocular pressure in ocular hypertension or in open-angle glaucoma if other
drugs cannot control the condition adequately or are not tolerated. Patients
should be monitored for any changes to eye coloration since an increase in the
brown pigment in the iris may occur; particular care is required in those
receiving treatment to one eye only.
First
line:
Latanoprost eye drops: 0.005%: (Xalatan®) [2.5ml £12.48]. Dose: one drop
daily.
Latanoprost eye drops: 0.005% + timolol 0.5%:
(Xalacom®) [2.5ml £14.32]. Dose:
one drop daily.
Second line:
For patients who cannot tolerate or who do reach target intraocular pressure with
latanoprost.
Bimatoprost 0.03% eye drops: (Lumigan®)
[3ml £10.30]. Dose: one drop daily.
For patients diagnosed as intolerant to
eye preservatives
Tafluprost 0.0015% preservative free eye drops: (Saflutan®) [30 x 0.3ml £17.41]. Dose: one drop
daily, preferably in the evening.
Miotics (cholinergics)
First choice: Pilocarpine eye drops: 0.5%
[10ml £1.30]; 1% [10ml £2.82]; 2% [£2.77]; 3% [£1.55]; 4% [£3.60].
Pilocarpine single use eye drops: 2%
[20 x 0.5ml £10.04].
Dose: 1 drop up to 4-6 times daily; for acute closed angle glaucoma pilocarpine 4% 1 drop every 5-15mins.
Caution: Ciliary spasm, cicatrizing conjuctivitis. Systemic absorption may cause sweating, bradycardia, intestinal colic, hypersalivation
and bronchospasm.
These are used for anaesthesia prior to tonometry,
removal of foreign bodies, minor conjunctival and
corneal surgery. Anaesthetised eyes should be padded to protect from dust and
bacteria and patients should be advised not to touch their eyes for at least
30mins after a procedure. Anaesthetised eyes should be padded to protect them
from dust and bacteria. If this is impracticable patients should be advised to
avoid dust and not to touch their eyes for at least 30 minutes after a
procedure.
First choice (for anaesthesia only): Proxymetacaine
single use drops: 0.5% [20 x 0.5ml £9.51].
Also:
Oxybuprocaine single use drops: 0.4% [20 x 0.5ml
£8.92].
Tetracaine single use eye drops: 0.5%
& 1% (BAN = amethocaine) [20 x 0.5ml £8.93].
First choice (for anaesthesia with staining): Proxymetacaine
0.5% and fluorescein 0.25% single use drops: [20
x 0.5ml £10.59].
Artificial tears and lubricants are used for dry eye syndromes. Where
troublesome mucus is present acetylcysteine
may also help.
First choice: Hypromellose eye drops: 0.3% [10ml
£1.60]. Dose: 1 drop as needed to relieve irritation or dryness. Caution:
Prolonged and frequent use causes preservative toxicity in 9% of patients so
those at risk should use preservative free drops. Different preparations vary
in their osmolarity.
Also:
Acetylcysteine 5% without preservative eye drops: (Moorfields) [10ml £14.41].
Carmellose single
use drops: (Celluvisc®) 0.5% [30 x 0.4ml £5.75]; 1% [30 x 0.4ml £3.00].
Hypromellose preservative free eye drops:
0.3% (Moorfields) [30 x 0.4ml £4.60].
Polyvinyl alcohol eye drops: 1.4% (Sno Tears®)
[10ml £1.06].
Simple eye ointment: [4g £3.22].
Lacri-lube® ointment:
[3.5g £2.28].
Carbomer 0.2% liquid gel: (Viscotears®): [10g £2.94], preservative free [30 x 0.6ml £5.42].
11.8.2 Ocular diagnostic and perioperative preparations and photodynamic treatment
11.8.2.1 Ocular diagnostic preparations
First choice: Fluorescein sodium single use
drops: 1% & 2%, [20 x 0.5ml £7.53]. Contact lenses, if worn, should be
removed and 1 drop applied to damaged areas. Conjunctival
abrasions stain yellow or orange, corneal abrasions or ulcers stain bright
green and foreign bodies are surrounded by a green ring. Excess should be
washed away with sodium chloride solution 0.9%.
Fluoret fluorescein
strip: 1mg, for detecting corneal and conjunctival
ulcers and epithelial defects. The strip is moistened with sterile sodium
chloride solution 0.9% and the tip stroked across the conjunctiva with the eye
looking down, after which the patient should blink several times [100 strips
£5.92].
Vision Blue: [0.5ml syringe £16.50].
11.8.2.2
Subfoveal choroidal neovascularisation
Pegaptanib and ranibizumab are vascular endothelial growth factor
inhibitors licensed for the treatment of neovascular
(wet) age-related macular degeneration; they are given by intravitreal
injection by specialists experienced in the management of this condition.
|
Link to NICE guidance |
Macular degeneration (age related) ranibizimab & pegaptanib. No.155 |
For specialist use only
Ranibizumab solution for intravitreal
injection: (Lucentis®): 10mg/ml [0.23ml vial £761.20]. Dose: see BNF. NB antimicrobial eye
drops should be administered into the affected eye for 3 days before and 3 days
after each injection.
The cause of a chemical burn needs to be
identified. The eye should be irrigated thoroughly until the fornices are neutral to universal indicator paper.
Sodium citrate eye drops: 10.11% (equivalent to citrate 6.5%), for acid
and alkali burns (Moorfields) [10ml £17.55] Dose:
1 drop every 0.5-2hrs initially, the frequency reduced
as needed but treatment continued until the epithelium has healed.
Potassium ascorbate eye drops: (equivalent to
ascorbic acid 10%), eye drops are used in conjunction with sodium citrate drops
at the same frequency (Moorfields) [10ml £16.82].
11.8.2.4 Other preparations
Operating theatre use:
Acetylcholine chloride injection: (Miochol-E®)
1% [2ml £7.28].
Apraclonidine ophthalmic soln: (Iopidine®) 1% [0.25ml £3.24].
Balanced salt soln: [19ml £0.95; 500ml £2.50].
Flurbiprofen single use eye drops: 0.03%
[40 x 0.4ml £37.15].
Hyaluronidase injection: 1500 units
[£7.60].
Ketorolac eye drops: (Acular®)
0.5% [5ml £3.00].
Sodium hyaluronate injection: 10mg/ml [0.85ml
£10.80].
Sodium hyaluronate injection: (GV) 14mg/ml
[0.55ml £27.00].
Miscellaneous:
Apraclonidine eye drops: (Iopidine®)
0.5% [5ml £10.88].
Betamethasone sodium phosphate injection: 4mg
in 1ml [£1.22].
Disodium edetate (EDTA) eye drops: 0.37% (Moorfields) [10ml £12.11].
Disodium edetate (EDTA) eye lotion: 0.37% (Moorfields) [20ml £55.67].
Sodium chloride eye drops: 0.9% [10ml £1.15]
Sodium chloride single use drops: 0.9% [20 x 0.5ml £6.80].
Sodium chloride eye drops: 5% (
Sodium chloride eye drops (unpreserved): 5% (
Zinc sulphate eye drops: 0.25% [10ml £3.78].
For expert use:
Botulinum toxin: 100 units (Botox®).
[£138.20].
Botulinum toxin: 500 units (Dysport®). [£154.00].
Contact lenses should be avoided during topical ocular therapy or should
only be worn on medical advice. If they are worn, ointments and oily drops
should not be used.
Soft lenses (hydrophilic) can absorb preservatives in eye drops causing
irritation and sensitivity.
Drops containing benzalkonium chloride should never
be used. Thiomersal is usually satisfactory and chlorhexidine rarely causes irritation.
Soft lenses may be stained by topical adrenaline, fluorescein,
phenylephrine and Rose Bengal and by systemic phenolpthalein, rifampicin, sulphasalzine and tetracyclines.
Rigid lenses (hydrophobic) do not absorb preservatives but benzalkonium
chloride can cause irritation. Rigid lenses with a hydrophilic surface should
not come into contact with any solution containing benzalkonium
chloride. Anti-inflammatory drops should not be used for prolonged periods.
Lubricants are available for hot dry eyes when contact lenses are used for
medical reasons.
For papillary conjunctivitis induced by contact lenses:
Sodium cromoglicate eye drops 2% (see 11.4.2).
11.9.2 Primary care of contact lenses
Contact lens care products are only available from the hospital
Ophthalmology Dept if lenses are fitted for medical reasons.
Soft lenses should be rinsed with sodium chloride solution 0.9% before wearing.
Gas permeable and hard lenses should be wetted with 2 drops of polyvinyl alcohol
1.4% unless a wetting /soaking solution has been used.
For soft contact lenses:
Oxysept® 1 Step: [90 day pack £22.79].
For rigid gas permeable and hard contact
lenses
Boston®
conditioning solution: [120ml £4.58].
Boston® cleaner: [30ml £4.58]
Total Care® disinfecting, storing and wetting solution: [120ml
£4.57].
Total Care® daily cleaner: [30ml £4.42].
For all types of contact lenses
Amiclair® contact lens cleanser
tabs: [24 tabs £5.58].
Lens Plus Ocupure® saline: [360ml
£2.07].
Quattro® Multifunctional solution: [250ml
£5.45]. NB 100ml starter pack available.